therapy Flashcards
what is CBT particularly good at treating
depression, anxiety, phobias, OCD, PTSD
what is the main principle of CBT
How our thoughts relate to our feelings and behaviour
what focus CBT focus on
Focus on here and now, problem focused, goal- orientated
in what ways can CBT be given
Individual, group, self-help book or computer programme
Therapist helps client:
what things does a CBT therapist help a client to do
¥ Identify thoughts, feelings and behaviours
¥ Assess whether thoughts are unrealistic / unhelpful (question own thoughts)
¥ Identify what can change
¥ Confront their fears – with preparation
what type of therapy gives out homework
CBT - client must be motivated
what is the evidence behind behavioural activation
Evidence that activities function as avoidance and escape from aversive thoughts, feeling and external situations
in behavioural activation, what is the client taught
to analyse unintended consequences of their way of responding
what is the lime limit of interpersonal therapy
12-16 weeks
what are advantages of interpersonal therapy
A grade evidence for treating depression
No formal homework – may be preferable
Client can continue to practise skills beyond the sessions ending
what are limitations of interpersonal therapy
Requires degree of ability to reflect – may be difficult for some
Poor social networks – limited interpersonal support to talk about in session
what do patients do in interpersonal therapy
construct an interpersonal map
Identify the interpersonal context
Looks at relationships and symptoms
work on focus area
what are the principles of motivational interviewing
Express empathy - Understand person’s predicament
Avoid argument - If challenging patient’s position – makes defensive
Support self-efficacy - Patient sets agenda, generates what they might consider changing
what are the 5 stages of change in motivational interviewing
pre- contemplation contemplation planning action maintainging
describe motivational interviewing at each stage of change
Pre- contemplation - not much can be done to help
Contemplation – Provide information, risk screening, pros and cons
Planning - Give options for change, build confidence & motivation
Action - Prevent relapsing and give coping strategies, Strategies to maintain goals, encouragement in failures
Maintaining - Coping strategies, weak points, emergencies, slip back protocols
what is the delayed response for many psych meds
3-6 weeks
what is the aim when prescribing in psychiatry
simplest drug regime
acceptable side effect profile
lowest effective dose
what are indications for anti-depressants
Unipolar and bipolar depression organic mood disorders, schizoaffective disorder anxiety disorders including OCD, panic attacks social phobia
what would you do if the patient is showing no response to anti-depressants after 2 months at an adequate dose
switch to another anti-depressant
augment with another
give some classes of anti - depressants
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
Tricyclics (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)
how is treatment resistant depression treated
Combination of antidepressants e.g. SSRI or SNRI with Mirtazepine
Adjunctive treatment with Lithium
Adjunctive treatment with atypical antipsychotic e.g. Quetipaine, Olanzapine or Aripiprazole
ECT - electroconvulsive therapy,
how does ECT work
induced seizure. Slowing dorsal cortex firing
what are side effects of ECT
headaches, shorter memory loss
how long should anti-depressants be prescribed after the 2nd episode of depression for prophylaxis
2 years
which is the most lethal antidepressant in overdose
TCA
what can tricyclics cause
QT lengthening
give examples of secondary TCAs
Desipramine, notrtriptyline
give example son tertiary TCAs
Imipramine, amitriptyline (chronic pain, neuropathic), doxepin, clomipramine
what are some side effects of tertiary TCA
antihistaminic (sedation and weight gain), anticholinergic (dry mouth, dry eyes, constipation, memory deficits and potentially delirium), antiadrenergic (orthostatic hypotension, sedation, sexual dysfunction)
what neurotransmitter so secondary and tertiary TCSs work on
secondary - noradrenaline
tertiary - serotonin
how do Monoamine Oxidase Inhibitors (MAOIs) work
Bind irreversibly to monoamine oxidase in the gut thereby preventing inactivation of amines such as norepinephrine, dopamine and serotonin leading to increased synaptic levels.
why are MAOIs not used in depression
side effects and risk of hypertensive crisis
what are some side effects of MAOis
orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction and sleep disturbance
when can hypertensive crisis occur with MAOI use
taken with tyramine-rich foods or sympathomimetics. *Cheese Reaction!!
when may serotonin syndrome occur
if take MAOI with meds that increase serotonin or have sympathomimetic actions
what are symptoms of serotonin syndrome
abdominal pain, diarrhea, sweats, tachycardia, HTN, myoclonus, irritability, delirium. Can lead eventually to hyperpyrexia, cardiovascular shock and death.
how do you avoid serotonin syndrome
wait 2 weeks before switching from an SSRI to an MAOI.
The exception of fluoxetine where need to wait 5 weeks because of long half-life.
how do SSRI’s work
Block the presynaptic serotonin reuptake
what are the most common side effects of SSRIs
GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue or sedation, dizziness
what symptoms may be seen is SSRI discontinuation syndrome
agitation, nausea, disequilibrium and dysphoria
what may be the immediate reaction to SSRIs
reaction to increased serotonin in the brain with nausea and more anxious - lead to a better response
insomnia
name some SSRIs
paroxetine sertraline fluoxetine citalopram escitalopram fluvoxamine
what is a pro of fluoxetine having a long half life
decreased incidence of discontinuation syndromes
good for patients with bad compliance
why is paroxetine goof if there is risk of hypomania
short half life - no active metabolites means no build up
why is paroxetine given at night
sedating properties
what are drawbacks of paroxetine
o Sedating, wt gain, more anticholinergic effects
o Likely to cause a discontinuation syndrome
which SSRI gives the most GI symptoms
sertraline
what is the biggest risk of citalopram
Dose-dependent QT interval prolongation with doses of 10-30mg daily- due to this risk doses of >40mg/day not recommended!
what is similar and different between TCAs and SNRIs
SNRIs Inhibit both serotonin and noradrenergic reuptake like the TCAS but without the antihistamine, antiadrenergic or anticholinergic side effects
name 2 SNRIs
venlafaxine
duloxetine
why is venlafaxine good for the geriatric population
fast renal clearance
what is a major con of venlafaxine
Can cause a 10-15 mmHG dose dependent increase in diastolic BP.
May cause significant nausea, primarily with immediate-release (IR) tabss
mAny sexual side effects
name 2 novel antidepressants
mirtazapine
buproprion
what are side effects of mertazapine (novel antidepressants )
o Increases serum cholesterol by 20% in 15% of patients and triglycerides in 6% of patients
o Very sedating at lower doses. At doses 30mg and above it can become activating and require change of administration time to the morning.
Increases appetite - weight gain (particularly at doses below 45mg
what are indications to prescribe mood stabilisers
Bipolar, cyclothymia, schizoaffective
what classes of drugs are used as mood stabilisers
Lithium, anticonvulsants, antipsychotics
what is the only medication proven to reduce suiceide rate
lithium
what is the gold standard drug for major depression
lithium
what factors predict positive response to lithium
o Prior long-term response or family member with good response
o Classic pure mania
o Mania is followed by depression
what should you do before starting a patient of lithium
Get baseline U&E and TSH
women - pregnancy test
how should you monitor someone on lithium
Steady state achieved after 5 days- check 12 hours after last dose.
Once stable check q 3 months and TSH and creatinine q 6 months.
what is the goal blood level of lithium
0.6- 1.2
what anomaly associated with lithium makes it teratogenic
Ebstein’s anomaly - cardiac
what are the most common side effect of lithium
GI distress including reduced appetite, nausea/vomiting, diarrhea
hypothyroidism
non significant leukocytosis
o Hair loss, acne
o Reduces seizure threshold, cognitive slowing, intention tremor
what are signs of mild lithium toxicity (1.5-2)
watch for vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus
what are signs of moderate lithium toxicity (2-2.5)
nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions,
delirium, syncope
what are signs of severe lithium toxicity (>2.5)
generalized convulsions, oliguria, renal failure, death
what antipsychotics are licensed in bipolar
Aripiprazole Risperdone Quetiapine Quetiapine XR Olanzapine
what are anxiolytics used to treat
panic disorder, generalized Anxiety disorder, substance-related disorders and their withdrawal, insomnias and parasomnias. I
what are anxiolytics often paired with to treat anxiety
SSRI/ SNRI
name 2 anxiolytics
Buspirone (Buspar)
Benzodiazapines
what psych conditions are Benzodiazapines sometimes used to treat
insomnia, parasomnias and anxiety
CNS depressant withdrawal protocols ex. ETOH withdrawal
how do benzodiazepines work
Works on GABA receptors to sedate brain, brain becomes used to it so need higher dose, dependence occurs.
what are side effects of benzodiazepines
Somnolence Cognitive deficits Amnesia Disinhibition Tolerance - Dependence
name 2 benzodiazepines
diazepam, lorazepam
what is buspirone not used in the acute setting (anxiolytics)
Takes around 2 weeks before patients notice results
what anti-convulsants are used in treating psychiatric disorders
valproic acid
carbamazepine
lamotrigigine
what are side effects of lamotrigine
o Nausea/vomiting
o Sedation, dizziness, ataxia and confusion
The most severe are toxic epidermal necrolysis and Stevens Johnson’s Syndrome (
why should you discontinue lamotrigine immediately if any rash appears
risk of steven johnson syndrome / toxic epidermal necrosis
what is the first line agent for acute mania and mania prophylaxis
Carbamazepine (Tegretol)
what should you check before prescribing carbamazepine
baseline liver function tests, FBC and an ECG
what are side effects of carbamazepine
o Rash- most common SE seen
o Nausea, vomiting, diarrhea
o Sedation, dizziness, ataxia, confusion
o AV conduction delays
o Aplastic anemia and agranulocytosis (rare - <0.002%)
o Water retention due to vasopressin-like effect which can result in hyponatremia
how is carbamazepine a heteroinducer
induces its own metabolism and that of others - contraceptives, warfarin, antidepressants
why is valproic acid not first line with bipolar when it is as effective as lithium at mania prophylaxis
not as effective in depression prophylaxis.
better tolerance than lithium
what are side effects of sodium valproate/ valproic acid
o Thrombocytopenia and platelet dysfunction
o Nausea, vomiting, weight gain
o Sedation, tremor
o Increased risk of neural tube defect 1-2% vs 0.14-0.2% in general population secondary to reduction in folic acid. NOT advised for women of child bearing age.
o Hair loss (alopecia)
what should you do before prescribing valproic acid
baseline liver function tests (lfts), pregnancy test and FBC. Start folic acid supplement in women
what are the 4 key pathways affected by dopamine in the brain
mesocortical
mesolimbic
nigrostriatal
tuberoinfindivular
when are antipsychotics indicated
schrizophrenia prophylaxis
low dose bipolar - mood stabilisation/ psychotic features
augmentation in anxiety
what can dopamine hypoactivity cause
Parkinsonian movements i.e. rigidity, bradykinesia, tremors), akathisia and dystonia
what does blocking dopamine in the tuberoinfundibulum pathway predispose a patient to
hyperprolactinemia (gynecomastia/galactorrhea/decreased libido/menstrual dysfunction).
what is the mechanism of most anti-psychotics
dopamine receptor antagonists
give examples of low potency anti-psychotics
chlorpromazine and Thioridazine
give examples of high potency anti-psychotics
include Fluphenazine, Haloperidol, Pimozide
what side effects are seen in high potency anti-psychotics
extrapyramidal and sex side effects
what side effects are seen in low potency anti-psychotics
more cardiotoxic and anticholinergic adverse effects including sedation, hypotension
what is the mechanism of atypical anti-psychotics
serotonin-dopamine 2 antagonists (SDAs
how long should you put someone on an anti-psychotic before changing
8 weeks
what is Tardive Dyskinesia (TD
involuntary muscle movements that may not resolve with drug discontinuation- risk approx. 5% per year
(anti-psychotics)
what is Neuroleptic Malignant Syndrome (NMS)
Psychiatric emergency. Characterized by severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK and lfts. Potentially fatal.
give examples of Extrapyramidal side effects (EPS):
Acute dystonia, Parkinson syndrome, Akathisia, increased suicide
what is clozapine received fro
treatment resistant schizophrenia
what are side effects of clozapine
agranulocytosis - weekly blood draws x 6 months, then Q- 2weeks x 6 months)
Increased risk of seizures
Associated with the most sedation, weight gain, hyperlipidaemia and abnormal LFT’s
Increased risk of hypertriglyceridemia, hypercholesterolemia, hyperglycemia,
what is a major drawback of olanzapine + Quetiapine (atypical anti-psychotic)
weight gain (30-50lb) hypertriglyceridemia, hypercholesterolemia, hyperglycemia
which atypical antipsychotic has a unique mechanism
Aripiprazole - action as a D2 partial agonist
what baseline blood work would you do before antipsychotics>
Fasting lipid profile. Fasting blood sugar, Lfts, CBC
what is a common side effect of siperidone (atypical antipsychotic)
akathisia
increases risk of suicide
is the first presentation of bipolar is manic, what mood stabiliser will she do better on
lithium
what is a common blood finding of pateitns of anticonvulsants
increased LFTs
up to 3x don’t change
